Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

The excimer laser is a light therapy used to treat small areas of psoriasis that have not responded to at least three months of other forms of therapy. It is not practical to treat more than 10% of body surface area with the laser.

Excimer Laser treatment requires pre-authorization.

Excimer laser treatment is eligible for benefits for persons with mild to moderate localized plaque psoriasis (L40.0, L40.8) affecting 10% or less of their body area who have failed to adequately respond to methotrexate and three or more months of topical treatments, with three or more of the following: HAYES C

1. High potency corticosteroids (examples include Fluocinonide cream and betamethasone dipropionate ointment);
2. Vitamin D derivatives: calcipotriene;
3. Retinoids: tazarotene;
4. Anthralin;
5. Tar preparations; and/or
6. Keratolytic agents: salicylic acid, lactic acid, urea.

Codes Used In This BI:

96920             Laser treatment for inflammatory skin disease (psoriasis); total area less                            than 250 sq cm

96921             Laser treatment for inflammatory skin disease (psoriasis); 250 - 500 sq cm

96922             Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

No more than 13 laser treatments per course and three courses per year are generally considered medically necessary. Preauthorization may be requested and/or granted by treatment or by treatment course.

Additional courses are not covered if the person fails to respond to an initial course of laser therapy, as documented by a reduction in Psoriasis Area and Severity Index (PASI) score or other objective response measurement.

The XTRAC is a handheld laser device that uses a xenon chloride source and provides intense, targeted UVB light. The potential benefits over standard UVB treatments are in terms of more rapid clinical response and more targeted therapy, avoiding the side effects of ultraviolet light exposure to unaffected skin. This procedure is usually repeated at least twice a week for 2-4 weeks.

Feldman, et al. (2002) reported on a multicenter study of the excimer laser involving 124 patients with stable mild-to-moderate plaque-type psoriasis, 32 of whom dropped out of the study before completing the course of treatment. Patients were scheduled twice weekly for a total of 10 treatments. Seventy-two percent of patients who completed the treatment course achieved at least 75% clearing in an average of 6.2 treatments. Eighty-four percent of patients reached improvement of 75% or better after 10 or fewer treatments.

The authors concluded that the excimer laser appears to be safe and effective for psoriasis, and has an advantage over conventional photochemotherapy in that it requires fewer visits and targets only the affective areas of skin, sparing the surrounding uninvolved skin.

Thus, the excimer laser may be considered as a treatment option for those patients in whom topical therapy has failed. According to published clinical studies, responses increase with up to 13 treatments, and the typical duration of response is 4 to 6 months. Additionally, clinical trials of the laser therapy selected patients with less than 10% of body surface area affected because, in the clinical setting, it is not practical to treat more than 10% of body surface area with the laser, because of the extended treatment time required due to the relatively small treatment spot size.

1.    Asawanonda P, Anderson RR, Chang Y, Taylor CR. 308-nm excimer laser for the treatment of psoriasis: A dose-response study. Arch Dermatol. 2000; 136(5):619-624. Available at: http://www.photomedex.com/media/308nm.pdf .

2.    Kemény L, Bónis B, Dobozy A, et al. 308-nm excimer laser therapy for psoriasis. Arch Dermatol. 2001; 1371):95-96.

3.    Asawanonda P, Anderson RR, Taylor CR. Pendulaser carbon dioxide resurfacing laser versus electrodessication with curettage in the treatment of isolated, recalcitrant psoriatic plaques. J Am Acad Dermatol. 2000; 42(4):660-666.

4.    Boehncke WH, Ochsendorf F, Wolter M, Kaufmann R. Ablative techniques in Psoriasis vulgaris resistant to conventional therapies. Dermatol Surg. 1999; 25(8):618-621.

5.    U.S. Food and Drug Administration. 510(k) Summary. PhotoMedex Inc. XTRAC Excimer Laser System, model AL 7000. 510(k) No. K003705. Rockville, MD: FDA; March 1, 2001. Available at: http://www.fda.gov/cdrh/pdf/k003705.pdf .

6.    Griffiths CEM, Clark CM, Chalmers RJG, et al. A systematic review of treatments for severe psoriasis. Executive Summary. Health Technol Asses. 2000; 4(40). Available at: http://www.ncchta.org/execsumm/summ440.htm.

7.    Feldman SR, Mellen BG, Housman TS, et al. Efficacy of the 308-nm excimer laser for treatment of psoriasis: Results of a multicenter study. J Am Acad Dermatol. 2002; 46(6):900-906.

8.    Hayes; Laser Therapy for Psoriasis, June 24, 2003

9.    Feldman SR. Remissions of psoriasis with excimer laser treatment. Dermatol Online J. 2003; 8(2):23.

10.  Rodewald EJ, Housman TS, Mellen BG, Feldman SR. Follow-up survey of 308-nm laser treatment of psoriasis. Lasers Surg Med. 2002; 31(3):202-206.

11.  Rodewald EJ, Housman TS, Mellen BG, Feldman SR. The efficacy of 308 nm laser treatment of psoriasis compared to historical controls. Dermatol Online J. 2003; 7(2):4.

12.  Taneja A, Trehan M, Taylor CR. 308-nm excimer laser of the treatment of psoriasis. Induration-based dosimetry. Arch Dermatol. 2003; 139(6):759-764.

Addendum:

Effective 10/01/2017: Added requirement for not responding adequately to oral methotrexate.

Resource Document:

BI125 Excimer Laser for Psoriasis